Epidurals and Other Drugs

Midwives have long been the guardians of normal physiologic birth, recognizing that labor
often does not progress as efficiently and safely
when interrupted by routine procedures or unnecessary interventions.

A routine epidural
turns deadly - Julie Ellis and Chris LeMoult were excited
parents-to-be. Did a hospital infection turn the happiest day of
their lives into a nightmare? [Dateline NBC 6/4/06]

What happened to Julie? - What started out as one of the happiest
days in a family's life ended as the most tragic. Did a hospital
infection cause an apparently healthy 28-year-old woman to be in
critical condition?

There's been a lot of criticism about the methodology of the
above study . . . in particular, their "control" group still
involved epidurals; there was no comparison to unmedicated
labors. Here's a good rebuttal:

"Jan 23, 2003 - Although epidural analgesia during labor may be
linked to short-term maternal side effects, its beneficial effects
on neonatal acid-base status probably outweigh these adverse
effects, according to a recent report." Gee, that just about
makes epidurals sound like the greatest thing since sliced bread,
right? Well, not if you read the fine print. 'Analysis
of data from the randomized studies revealed that epidural
analgesia was associated with significantly higher fetal pHs than
was systemic opioid analgesia. " Yep. I'll be the
first to say that systemic opioid analgesia (i.e. IV narcotics -
e.g. stadol, nubain, fentanyl) is worse for the baby, but has
medicine so given up on rational discourse that nobody thought to
consider how either of these compared to birth without any drugs
other than the mother's own endorphines - nature's own pain
relief. (NOTE - women who labor in anxiety-producing
environments without adequate labor support will not be relaxed
enough to benefit from the endorphines nature provides along with
contractions; they may well feel that they need some pain relief,
and epidurals do seem to be less damaging to the baby than IV
narcotics.)

Demerol

For those of you in hospital settings, especially, are you still
seeing a lot of demerol being used for moms who don't get
epidurals and want meds? I have never been particularly impressed
with demerol as a pain reliever and I am wondering how it got to
be so widely used when other medications are potentially more
effective in relieving pain..... thoughts anyone? Maybe this is
one that some of our physician colleagues on the list have more
insight into.

My experience agrees with yours and I have met only a few
midwives who like demerol.

Male-medical-model driven! Probably right up there with how
episiotomies got to be used so injudiciously!

Pharmacologist Tom Hale, author of "Medications and Mothers Milk"
has recommended against meperidine (demerol) use in labor and
post-partum because it has an active metabolite (normeperidine)
with a half life in newborns of over 50 hours. He believes this
leads to excessive sedation and failure to breastfeed effectively
for the first few days of life. He prefers alfentanil and
sufentanil for epidurals and morphine for parenteral
administration, if any narcotic is given.

I have never been particularly impressed with demerol as a pain
reliever.

Morphine

I can manage (I hate that word!) most moms so that they labor
drug free. But there is that small percentage (abuse victims,
prolonged latent/prodromal, abnormal labors) where a narcotic is
indicated.

If so, I like to use a narcotic that is pure narcotic (not
agonist/antagonist like nubain or stadol), does not have a toxic
metabolite (like meperidine/pethidine/demerol) and has a proven
track record of efficacy. Hence morphine. I agree, it's a very
controversial opinion to hold. But it is carefully thought
through. I do not know of much real research on the efficacy of
various narcotics in labor, just a few studies comparing narcotic
to epidural.

I have long held the controversial and minority opinion that if a
woman in labor truly needs a narcotic medication (and that is
another can of worms I won't address just now) that morphine is
safer and more effective than demerol, both for her and her baby.
All narcotics carry risks, the most widely disseminated one being
that of fetal respiratory depression. Morphine, being a pure
agonist narcotic, is readily and completely reversed by Narcan,
something that doesn't seem to be true of Nubain and Stadol. It
also doesn't have the toxic metabolite (normeperidine) that
Brazelton's studies in the 1960s showed hung around in the newborn
for a week after mom's intrapartum exposure. It also works very
well.

I, too, like Morphine. When a mom has been going at the latent
phase for "days" and doesn't seem to be getting any rest I would
prefer to start out with Vistaril 100mg IM. This is because I can
send her home after the injection. The hospital policy states that
any mom given Morphine must stay. But if the mom looks truly
wasted, doesn't have a quiet supportive environment to go to,
dehydrated, support people aren't, etc..... I will admit her and
"sleep" her. I don't use Seconal in combination with the Morphine.
Some do. When she wakes, if she is in active labor--GREAT. If not
in labor--GREAT. She got some much needed sleep and can now get on
with whatever she needs to do--labor or continue to rest.

Why not just give her Vistaril 100mg po to take home and take
once she's home. This usually works, although occasionally women
describe not being relaxed after taking it.

Because I used to give PO Vistaril and didn't get the results
that I get with IM. Too many pts were back in two hours
complaining of no relief. So I have gone to IM as my first choice.

Morphine as a Uterotonic

When John Hobbins was at Yale as Chief of OB (he has since married a
midwife and is in Denver), he was pretty insistent that morphine is
a uterotonic drug....ie actually improved/strengthened contractions.
I think this is why it works so well when we sleep someone with
prolonged latent phase. I routinely see someone wake up 6-7 cm after
morphine and vistaril.

Like others, I never use seconal. Too much hangover for mom, FH
is not reactive (so the nurses get upset and want to do continuous
monitoring.....and that's a whole big fight to get mom off the
monitor once she is in active labor).

Having come from a place where (as a labor nurse eons ago)
Demerol was the only narcotic available, I will NEVER use
it again! Too much vomiting, and the metabolite (normeperidine)
lasts longer than the demerol itself, and it has a much longer
lasting respiratory depressive effect on the neonate.

We use nubain/vistaril if necessary in labor. Not great,
but no vomiting, no major probs with the newborn. (of course my
favorite pain relief measure is the shower!)

Nitrous Oxide / Gas and Air

There were no significant differences found for any of the
outcomes in the studies comparing one strength versus a different
strength of inhaled analgesia, in studies comparing different
delivery systems or in the study comparing inhaled analgesia with
TENS.

Entonox
-
Gas and Air - This is a 50-50 mixture of nitrous oxide and
oxygen that you inhale through a mask or mouthpiece. It acts in
about 30 seconds and makes you light-headed for a minute or so
before wearing off.

It enters your bloodstream and crosses the placenta, but in tiny
amounts as it's exhaled almost immediately. It has little effect
on your baby .

Inhaled
Analgesics Take the Edge Off Labor Pain [10/29/12] -
Although inhaled analgesic pain relief during labor is generally
not an option in the United States and most other countries,
except the United Kingdom and Canada, researchers have found that
inhaled nitrous oxide and flurane derivatives are an effective
means of reducing the intensity of labor pain.

"Gas and air" appears to be used frequently in the UK as a
self-administered relaxing agent, both in and out-of-hospital.

In some ways, I think it would be a fabulous option for women in
the US as well. I've heard that some hospitals are starting
to offer it, and I would like to see its use investigated for
homebirth as well.

Conclusions A dose response relationship between fentanyl
and artificial feeding has not been reported elsewhere. When
well-established determinants of infant feeding are accounted for,
intrapartum fentanyl may impede establishment of breastfeeding,
particularly at higher doses.

I see a small amount of Demerol here in eastern Atlanta. The drug
of choice seems to be Stadol. Some Nubain, and Fentanyl for short
term relief (< 1 hour).

I've seen the same thing. I ordered Stadol and phenergan once and
the nurses and other midwives thought I was from another planet. I
really hate Nubain and there is a pretty good article in the green
journal discussing the woes of Nubain's effect on the fetal heart
rate tracing (will look for it if someone wants the exact
citation).

CONCLUSION: In the early intrapartum period of normal
term pregnancies and at commonly used dosages, nalbuphine had a
significant effect on FHR tracings, whereas meperidine had no
effect, as determined by computer analysis.

I've been following the digest postings on this with some
interest. in my opinion, formed from somewhat limited experience
(doing L & D nursing in hospitals for about 2 years, but the
first year and a half was at a 25 bed hospital where we only did
150 births/year and didn't use nubain), demerol is almost never a
good choice. actually, this opinion first formed when my
pharmacology professor would go into rants about demerol, which he
hated with a passion (he said there were two standards of care for
pain management--aspirin and morphine :-)), but be that as it may,
my experience with demerol is it makes people puke. if you combine
it with phenergan, as docs often do, it makes people puke a little
less, but they have to deal with the phenergan in their system,
which can last quite a while and make you quite woozy.

so when i'm talking with my laboring moms, and they're interested
in options (as opposed to the sad majority who come in just
wanting their epidurals as soon as possible), i encourage nubain
over demerol any day. we used stadol at the hospital i used to
work in (the 25 bed one), but in lower doses than the docs seem to
order here, and the couple times i've given the higher doses it's
really seemed to zonker the moms out considerably more than the
other meds do.

anyway, we tend to call nubain the "marguarita shot," and for
some women it really works wonderfully--it enables them to really
relax and go into that "nubain slide" that two of my moms did last
week, both going from 4-5 centimeters to delivery in half an hour
(and one was a primip). for other women it enables them to hang on
long enough for their epidural. of course, it definitely affects
the baby--both those babies last week needed narcan, but then they
both did great after that.

A letter
in response to the article, written by Ronnie Falcao,
emphasizing the harm that epidurals do in depriving a baby of pain
relief during labor and depriving the mother and baby of the
bonding hormones at birth.

Ok guys. Help me out here. How would you, as a midwife or
educator, respond to the increasingly common statement: "Oh, I
loved my epidural. It is the only way to go. Yes, I did end up
with Pitocin and then because of low heart tones, a cesarean. But
I would definitely have another epidural."

I know that in certain cases epidurals are very helpful. However,
they are becoming the only way to go where I teach. Women, even
after knowing of the possible side effects, still want them. I
feel like we are going backwards here. On the other hand, midwives
are becoming increasingly available. So, that is at least good
news. However, the general population seems to be clamouring for
epidurals. Whatever happened to the natural childbirth movement?
Is it dead?

I taught childbirth classes for 10 years and used to feel the
same way that you do. Now I'm on the other side of the coin, an RN
in L&D and my viewpoint is changing. First of all, most
couples are not motivated to go "natural". While they may take
classes and say that they want to go without the use of drugs,
when she hits active labor, this all changes. Very rarely do I see
a truly supportive significant other that helps with the labor
support techniques learned in class. When the alternative is there
to be "pain free" and not to "suffer", 99% of the time, they will
opt for the epidural.

On the other hand, as an L&D nurse, I find myself not
discouraging the use of an epidural. We are a very busy unit, I
have done as many as 8 deliveries in one 12 hour shift, and I
simply cannot be there to help labor support this woman. I usually
have 2 laboring patients, and if one or both have an epidural, it
makes my job easier. I can usually catch up on my charting so that
I don't have to stay 1-2 hours of overtime to do it. As selfish as
this sounds, this is the reality with most nurses. If you work the
next night, the last thing you want to do is lose more sleep than
you already will.

Basically, couples today are not prepared, or motivated to do it
on their own. I believe we will continue to see this until
insurance companies stop paying for them.

Epidurals

Pain relief is important for women
in labour. Pharmacological methods of pain relief include
inhalation of nitrous oxide, injection of opioids and regional
analgesia with an epidural for a central nerve block. Epidurals
are widely used for pain relief in labour and involve an injection
of a local anaesthetic into the lower region of the spine close to
the nerves that transmit pain. Epidural solutions are given by
bolus injection, continuous infusion or using a patient-controlled
pump. Lower concentrations of local anaesthetic are needed when
they are given together with an opiate, allowing women to maintain
the ability to move around during labour and to bear down.
Epidural analgesia may sometimes give inadequate analgesia, which
may be due to non-uniform spread of local anaesthetic. Combined
spinal-epidural involves a single injection of local anaesthetic
or opiate into the cerebral spinal fluid for fast onset of pain
relief as well as insertion of the epidural catheter for
continuing pain relief. Side effects such as itchiness,
drowsiness, shivering and fever have been reported and rare but
potentially severe adverse effects of epidural analgesia do occur.

The review identified 38 randomised controlled studies involving
9658 women. All but five studies compared epidural analgesia with
opiates. Epidurals relieved labour pain better than other types of
pain medication but led to more use of instruments to assist with
the birth. Caesarean delivery rates did not differ overall and nor
were there effects of the epidural on the baby soon after birth;
fewer babies needed a drug (naloxone) to counter opiate use by the
mother for pain relief. The risk of caesarean section for fetal
distress was increased. Women who used epidurals were more likely
to have a longer delivery (second stage of labour), needed their
labour contractions stimulated with oxytocin, experienced very low
blood pressure, were unable to move for a period of time after the
birth (motor blockage), had problems passing urine (fluid
retention) and suffered fever. Long-term backache was no
different. Further research on reducing the adverse outcomes with
epidurals would be helpful.

Epidural Home
Page - sponsored by anesthesiologists, so this shows only
the good side of an epidural. It downplays the immediate
risks from the procedure and ignores secondary risks such as
effects on labor and the baby.

Here's a study they did in which they acknowledge that "Epidural
analgesia is thought to . . . have a greater incidence of
complications than IV analgesia.". Notice that they do not
compare the risks of both these forms of analgesia with non-pharmacological forms of pain relief,
such as birthing tubs, doulas, hypnobirthing, TENS units,
etc. After all, they don't profit from non-pharmacological
pain relief.

Sylvie Donna, a British clinician [I think she's a midwife], has
written a new book. Here are some research excerpts from the
book Optimal Birth: What, Why & How by Sylvie Donna (Fresh
Heart, 2011). You can reach Sylvie at: <sylvie@freshheartpublishing.co.uk>
Book available from Amazon or directly from Fresh Heart at the
Fresh Heart

Sylvie recently agreed to share some of her research notes on
epidural anesthesia from the book Optimal Birth: What, Why &
How (Fresh Heart, 2010). In order to evaluate epidurals as a form
of pain relief, she told us that she decided to focus on these
topics:
Effect of epidurals on labor
Efficacy of epidurals for pain relief
Alertness postpartum
Breastfeeding rates

Effect of epidurals on labor:

The following studies strongly suggest that the physiological
processes are dramatically compromised when a woman has
pharmaceutical pain relief. It seems there is an inhibition of
catecholamine release (Jones, 1985) as well as an inhibition of
the oxytocin peak, which typically occurs during a physiological
labor (Goodfellow, 1983).

In the first study (Agaram, et al) the researchers initially
concluded (from women's reports) that 16.9% of women who'd been in
the cohort (of 260 subjects) experienced inadequate pain relief.
Problems were associated with insertion of the epidural at more
than 7cm dilation, women's past experience of opioid tolerance,
previous failed epidural and insertion of the epidural by a
trainee anesthesiologist. After adjustments, the researchers
concluded that epidurals were ineffective in only 9.3% of cases.
The second study (Le Coq, et al), which observed 456 women
(instead of interviewing them), found that epidurals provided
inadequate pain relief in labor in 5.3% of cases, and during
'delivery' (birth) in 19.7% of cases. Reasons for inadequacy (in
order of importance) included inadequate first doses (so that two
top-ups were needed), posterior position, pain when the epidural
was sited, epidural being in place for more than six hours, and
the epidural being in place for less than one hour (meaning it was
less effective for 'delivery'). Another related angle is to do
with later memories. In one study (which clearly needs to be
repeated), even when women reported good pain relief as a result
of an epidural, they generally reported
lower levels of satisfaction with the birth overall a year after
the birth.

Cooper, et al Satisfaction, control and pain relief: short and
long term assessments in a randomized controlled trial of low-dose
and traditional
epidurals and a non-epidural comparison group. International
Journal of Obstetric Anesthesia, 2009. [Full reference not
available at time of going to
press.]

Alertness postpartum:
Wittels, et al (1997) compared the alertness (amongst other
things) of newborns exposed to either epidural morphine or
intravenous patient-controlled analgesia. Of course, because the
focus was on newborns of mothers who'd had a cesarean it was
impossible to compare the alertness of babies born with drugs in
their systems and that of babies who'd been born with absolutely
no drugs in their system, so only 'relative' alertness could be
tracked. Yet another study, back in 1981 (Rosenblatt, et al)
looked at the influence of maternal analgesia (epidural
bupivacaine) on the newborn. Significant effects were found:
Immediately after delivery, infants with greater exposure to
bupivacaine in utero were more likely to be cyanotic
[blue-skinned] and unresponsive to their surroundings. Visual
skills and alertness decreased significantly with increases in the
cord blood concentration of bupivacaine, particularly on the first
day of
life but also throughout the next six weeks. Adverse effects of
bupivacaine levels on the infant's motor organization, his ability
to control his own state of consciousness and his physiological
response to stress were also observed. A recent study by Henrichs,
et al (2009) considered whether alertness could be affected by a
factor such as fetal size in mid- or late pregnancy. (The
conclusion was that it could.) In a study such as this, I would
imagine there could be numerous confounding factors, the principal
one being the use of anesthesia or analgesia (or not) during
labor. Personally, I would only trust the results of this study if
all fetuses measured in utero had been born without any drugs in
their systems. After all, while the motivation of these
researchers appears to have been a desire to investigate
behavioral problems in newborns (e.g. infant irritability),
they do not appear to have taken into account the fact that one of
the primary characteristics of narcotics-addicted neonates is that
they are 'substantially more irritable' (Strauss, et al, 1975).
Given the vital importance of good bonding in the sensitive
one-hour period following birth (from the point of view of later
mothering behavior), I very much hope that other researchers will
look further into the issue of alertness, particularly in relation
to drug-use in labor.

Hill D. Remifentanil patient-controlled analgesia
should be routinely available for use in labour. International
Journal of Obstetric Anesthesia, 2008, 17(4),336-339.
Van de Velde M. Controversy. Remifentanil
patient-controlled analgesia should be routinely available for use
in labour. International Journal of Obstetri
c Anesthesia, 2008 Oct;17(4):339-42. Epub 2008 Jul 9

Breastfeeding rates:
In a retrospective study conducted by Jordan, et al (Jordan, et
al, 2009), which looked at 48,366 healthy women birthing singleton
babies at term (i.e. women having healthy births), it was found
that at 48 hours after the birth, rates of breastfeeding
definitely seemed to be affected by epidurals, opioid analgesia
(Demerol, diamorphine, etc) and ergomentrine (used in the third
stage of labor). The researchers point out that failure to
breastfeed increases morbidity and mortality in both mothers and
children in developed and developing countries, so the impact of
any possible effects of drugs used unnecessarily could be
enormous. In this study, beyond sociological factors, which have
long been known to affect breastfeeding rates, lower
breast-feeding rates were associated with induction with pessaries
(prostaglandins), epidurals and opioid analgesia, and ergometrine
used for the third stage of labor. (Oddly, they found that
first-time mothers who'd had gas and air were more likely to
nurse. Could this be because these mothers were determined to
avoid drugs in labor as much as
possible, so as to have as 'natural' a birth as possible, and to
nurse successfully too? Any determination to avoid everything
except gas and air could be a particularly British attitude, which
is misguided, in my view, for other reasons, as I shall explain
later. The view that it is considered 'nothing' is reflected in
the off-hand statement made by many women postpartum: Oh, I only
had gas and air.) Anyway, the study by Jordan, et al does provide
some evidence that drug use in labor and birth has an impact on
breastfeeding rates at 48 hours postpartum, which obviously will
affect longer term rates too, although it must be said that this
evidence is not accepted by all anesthesiologists as prospective
randomized studies are seen as more reliable.After all, women
usually request epidurals because of difficulties, so it is not
necessarily epidurals per se which cause later problems.
Cause-effect are difficult to establish.Other (prospective)
studies reported fairly clear problems with narcotics used
in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et
al, 2006
). In the study by Beilin, et al researchers concluded: Among
women who breastfed previously, those who were randomly assigned
to receive high-dose labor epidural fentanyl were more likely to
have stopped breastfeeding 6 weeks postpartum than women who were
randomly assigned to receive less fentanyl or no fentanyl.
(Fentanyl was added to the drug bupivacain, in the epidural
cocktail as bupivacain causes paralysis in the lower part of the
body; adding fentanyl reduces this effect. Clearly, though, it's a
problem if too much is used.) The study by Torvaldsen, et al
concluded: Women in this cohort who had epidurals were less likely
to fully breastfeed their infant in the few days after birth and
more likely to stop breast-feeding in the first 24 weeks, although
the researchers felt they were unable to say whether there was a
causal link between epidural anesthesia and difficulties. This was
despite the fact that Intrapartum analgesia and type of birth were
associated with partial breastfeeding and breastfeeding
difficulties in the first postpartum week and the fact that women
who had epidurals were more likely to stop breastfeeding than
women who used non-pharmacologic methods of pain relief. Camann's
editorial (below) provides a good overview of this topic. See:
Jordan S, Emery, S, Watkins A, Evans JD, Storey M,
Morgan G. Association
s of drugs routinely given in labour with breastfeeding at 48
hours: analysis of the Cardiff Births Survey. BJOG: International
Journal of Obstetrics & Gynaecology, 2009, online publication
on 1 Sept
Beilin Y, Bodian C, Weiser J, et al. Effect of labor
epidural analgesia with and without fentanyl on infant
breast-feeding: a prospective, randomized, double blind study.
Anesthesiology, 2005, Dec;103(6):1211-7

Camann W. Labor analgesia and breast feeding: avoid
parenteral narcotics and provide lactation support. International
Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201
Torvaldsen S, Roberts CL, Simpson JM, et al.
Intrapartum epidural analgesia and breastfeeding: a prospective
cohort study. International Breastfeeding Journal, 2006,Dec11;1:24
Sylvie says: If research data which has emerged in the last
year has dramatically changed the picture, I'd like to hear about
it. The chapter on epidurals that Michael Klein recently wrote
just a few weeks ago for the upcoming Fresh Heart title Promoting
Normal Birth: Research, Reflections & Guidelines suggests that
the outlook for epidurals still looks the same.

Epidurals and Autism

At the 2001 APPPAH conference, Dr. Lewis Mehl-Madrona explained a
presumed mechanism for the pitocin/epidural/autism
connection. Because the newborn neurological system does not
yet have the protective myelin layers around the brain and nerves,
they are inflamed by the bupivicaine used in epidural anesthesia;
it destabilizes the membranes of the developing brain.. When
pitocin is also used (either for induction or augmentation), this
results in greater exposure to the oxytocin family than would
occur in a normal birth. Because of the nerve inflammation,
the nerves develop an adverse reaction to the high levels of
oxytocin . . . sort of an allergic reaction. Later in life,
when the child responds to social situations by the normal
production of oxytocin, this serves as a trigger for the allergic
reaction to oxytocin, and the child develops an adverse response
to social situations.

Breastfeeding is a social situation, stimulating oxytocin
production in both the mother and baby. Prolonged exposure
to both pitocin and epidural during labor could trigger the same
sort of aversive response to breastfeeding.

[Ed: People sometimes ask why there would be a difference between
pitocin and natural oxytocin. There may be chemical
differences, but one obvious difference is that pitocin is often
given before the uterus is fully mature, so the uterus hasn't
acquired all the oxytocin receptors of a term pregnancy. So
the amounts of pitocin used are often much greater than the body
would naturally produce.]

Epidural Fevers

Scary New Research About Epidurals Causing Harm to the Baby

For a long time, we've known that epidural use was associated
with maternal fever during labor. We used to think these
"epidural fevers" were harmless to the baby. New research
shows that they are actually associated with harm to the
baby. I hope they'll do a lot more research to figure out
what's really going on here. We need epidurals to facilitate
vaginal births on occasion. And women who are opting for
epidurals as a first resort need to know the real risks.

January 30, 2012 — Maternal fever that accompanies epidural
analgesia is associated with neurological depression in the
neonates, according to a study published
online January 30 in Pediatrics. . . . Of
women receiving epidurals, 535 (19.2%) developed fevers compared
with 10 of 425 (2.4%) of those not receiving epidurals. . . .
The researchers conclude that "increased maternal temperature,
regardless of etiology, may have implications for the fetus." After
adjusting for confounding factors, they associated maternal fever
above 101°F with a "two- to sixfold increase in the occurrence
of all adverse neonatal outcomes examined," they write.

CONCLUSIONS: The proportion of infants experiencing adverse outcomes
increased with the degree of epidural-related maternal temperature
elevation. Epidural use without temperature elevation was not
associated with any of the adverse outcomes we studied.

I know that epidurals can cause fevers, but why?

My understanding is that it has something to do with the nerves
that allow your body to sweat being numbed. Therefore, while your
body is doing the hard work of labor, it can't cool itself off the
natural way (sweating). My BIL is an anesthesiologist, and I
believe that is what he said. I would like to be corrected if this
isn't right though.

NEW YORK (Reuters Health) - Women who run a fever during labor
have an increased risk of giving birth to a child with a type of
brain damage called encephalopathy, according to a new report.

Since fever is often a sign of inflammation, the finding provides
additional evidence that inflammation may play a role in some
birth defects that affect the brain, the study's authors explain.

Studies have shown that both infection and fever during labor
increase the odds that a woman will give birth to a child with
cerebral palsy, and fever has been suspected of increasing the
risk of encephalopathy in infants. Some children with
encephalopathy die soon after birth and others develop permanent
neurological problems.

Despite the tentative link between fever during labor and
encephalopathy, it has been uncertain whether fever causes the
brain damage or is simply a sign, or "marker," of some other
factor that is the real cause.

Dr. Lawrence Impey of The John Radcliffe Hospital in Oxford,
England, and associates studied nearly 5,000 pregnant women who
were judged to be at low risk of having a baby with birth defects.
Overall, 336 (nearly 7%) of the women had fever during labor,
according to their report in the June issue of the British Journal
of Obstetrics and Gynaecology. Sixteen newborns developed
encephalopathy.

After taking into account several factors that could have
affected the risk of encephalopathy, including whether a woman had
given birth previously, the length of pregnancy and labor, and
whether labor was induced, the researchers calculated that the
risk of encephalopathy was increased nearly fivefold in babies
whose mothers ran a fever during labor.

"These data show that maternal fever in labour is strongly
associated with neonatal encephalopathy," Impey's team concludes.
They suggest that fever itself may somehow cause the brain damage,
although they do not rule out that fever is a marker of a chronic
or low-grade infection that might be the true cause of
encephalopathy. [SOURCE: British Journal of Obstetrics
and Gynaecology 2001;108:594-597.]

Much of fever during term labor may not be infectious
but rather a consequence of the use of epidural analgesia. . .
. Intrapartum maternal fever, particularly if >101
degrees F, was associated with a number of apparently transient
adverse effects in the newborn. Larger studies are needed to
investigate the association of intrapartum fever with neonatal
seizures and to determine whether any lasting injury to the fetus
may occur.

Several explanations have been proposed to account for
increased maternal temperature with the administration of epidural
analgesia. The pain relief associated with epidural analgesia may
result in decreased maternal hyperventilation, resulting in
decreased heat loss by this mechanism. However, reduced
sweating due to sympathetic blockade and reactive vasoconstriction
as well as a dissociation in warm and cold sensation due to the
sensory blockade of the epidural analgesia may account for an
increased incidence of fever (Fusi, et al 1989).
Furthermore, it has been postulated that epidural analgesia
results in altered thermoregulatory transmission from the
periphery to the hypothalamus, increasing the temperature set
point and resulting in fever (Camann, Hortvet, Hughes, Bader and
Datta, 1991).

The Fusi reference was in Lancet, 8649, 1250-2, and the other from
the British Journal of Anesthesia, 67, 565-8.

The rest of the MCN article really didn't have much exciting to
say, just that the WBC and other phenotypic measures measures of
leukocytes are not affected by epidurals. And contrary to
what you might expect from the title, they concluded that
epidurals appeared not to alter immune measures of infection in pp
women.

with Recommendations for clinical practice

Women who chose epidural analgesia in this study had a
markedly increased risk of intrapartum fever; likewise, their
newborns were more likely to require a sepsis work-up and
antibiotic treatment. It remains uncertain whether epidural
analgesia causes maternal fever or is just a risk marker.
Nevertheless, based on the strong association found in this study,
family physicians providing obstetrical care should discuss with
patients considering epidural analgesia the possible increased
risk of fever, sepsis evaluation and antibiotic treatment of their
neonates, in addition to the increased risk of operative delivery
(1).

Epidural Headaches

I know this lady who just had a baby in the hospital. She got an
epidural. VBAC was successful. Now here is the problem. She got a
terrible headache. Turned into a migraine. Cannot lift her head
off of the pillow.. The Labor Nurse said that something went wrong
when the anesthesiologist did the epi. Took him 45 minutes and
much frowning. Labor nurse said that it usually takes him 15
minutes to do one. Would not tell her what went wrong. They
checked her back and told her she was leaking spinal fluid!!

The anesthesiologist should be notified ASAP. This mom has a
super duper bad SPINAL headache because the epidural needle (which
is bigger bore than a spinal needle) accidentally punctured into
her spinal canal and caused the fluid to leak out. She has a
headache because her brain is not getting as much cushioning as
usual. There are effective treatments for this. The one that the
anesthesiologist can do is called an epidural blood patch. Another
effective treatment is to infuse sterile saline into the epidural
space. Things that the mom can do to help include drinking LARGE
amounts of fluids and ingesting caffeine.

If the doctor will not see her promptly, the nursing supervisor
should be called and asked to find a dr. (of anesthesia) who will.
If needed, this should be taken up the chain of command in the
hospital. This is totally unacceptable behavior, to leave a person
in pain of this kind due to a medical complication of her
anesthesia. It should not be tolerated by anyone.

Unfortunately the anaesthetist has punctured the dura of the
spine causing leakage of cerebrospinal fluid in turn causing a
postdural puncture headache! Apparently it happens in 1% of
epidurals.

She got the blood patch and it worked. The Dr told her that the
other Dr screwed the epidural up. Blamed it on lack of sleep!! She
still has the headache though. He said that this could last
awhile.

Timing in Epidural use in nulliparas associated with prolonged
labor.

(Reuters) Less-advanced cervical dilation upon hospital admission,
along with early epidural placement, are strongly associated with
prolonged labor, (defined as lasting more than 12 hours) according
to Dr. Fergal D. Malone from Ireland, and colleagues. When the
epidural was placed early in labor, that is before 2 centimeters
dilation, the risk increased 42-fold. Dr. Malone says, "...that it
is not the presence of the epidural that predisposes a woman to a
prolonged labor, but that the cervical dilation at the time of
epidural placement may be important." Obstet Gynecol 1996;88:211-215.

Epidurals Linked to Cesarean Sections

Thorp, JA et al. (1993) The effect of intrapartum epidural
anesthesia on nulliparous labor: a randomized, controlled,
prospective trial. American Journal of OB/GYN. 169 (4) 851-858.
Nulliparas in spontaneous labor were randomized to epidural (n=48)
or narcotic (n=45 analgesia. The only cesarean in the narcotic group
was the only woman who opted out into the epidural group. The risk
of cesarean with epidural was 50% at 2cm, 33% at 3cm, 26% at 4cm,
and nil at 5cm. They stopped the study early on ethical grounds when
the results became clear to the researchers.

Thorp JA et al. (1991) Epidural Anesthesia and cesarean section
for dystocia: Risk factors in nulliparas. American Journal of
Perinatology. 8(6) 402-410.
This study is even better, because they separately analysed and
compared groups of women receiving epidural at different dilations
and stations with groups of women receiving no epidural and then
further grouped them by their progress in labor and were therefore
able to compare the effect of the epidural on labor progress and
dystocia. It is fairly confusing to abstract, but the whole text
makes clear that epidural women were more likely to have oxytocin
and cesareans for dystocia.

Listers might be interested to know that a large multi-centre
trial is being mounted in Calgary, enrolling 1600 women. This
trial will hopefully address the methodological problems of some
of the previous work done in this area, including the problem with
cross-over. Outcome measures are: effect on progression of labour;
pain relief; a newborn's first day of life; breastfeeding; fever;
and back pain after delivery.

If you want to read more about it, go to the Web page.
Go to the August 15,1997 issue to the News and Analysis section.

I agree that it would be good to see epidurals compared to no
pharmaceutical pain relief. Unfortunately, a sad state of affairs
when the investigators likely realize that they couldn't recruit
enough women if the control group was randomized to nothing for
pain. Using doulas would be nice, but likely would be considered a
confounding variable.

Epidurals And Fetal Distress

The epidural anaesthesia was performed with bupivacaine in a
lateral position. [Please e-mail the
reference for this if you have it. Thanks!]

Results: After the insertion of the epidural needle a
change in the oscillation amplitude and an increase in variable
and late decelerations was observed. There were no significant
changes in the other CTG criteria and no changes in maternal heart
rate and blood pressure.

This is extremely interesting. This is something that I had
noticed clinically and while it used to be blamed on the
drop in maternal BP, now anesthesia staff is saying it is an
effect of the narcotics which they are using (in combination
with bupivacaine, marcaine and others). Since this
study based on those receiving the traditional anesthetic
without narcotic combo, would seem to indicate that narcs.
aren't the problem. We see a lot of problems with airway
clearance and babies that don't begin rooting within the
hour after birth - and I was just sure it was the narcotics
causing the problem.

Epidurals And Breastfeeding
Problems

CONCLUSION: Women in this cohort who had epidurals were less
likely to fully breastfeed their infant in the few days after
birth and more likely to stop breastfeeding in the first 24 weeks.
Although this relationship may not be causal, it is important that
women at higher risk of breastfeeding cessation are provided with
adequate breastfeeding assistance and support.

Epidurals And Long-Term Effects

"The epidural group showed poorer performance on the orientation
and motor clusters during the first month of life. Epidural
mothers reported spending less time with their infants while in
the hospital; post hoc analyses showed that they had longer labor,
more forceps deliveries and a greater amount of oxytocin.
Controlling for the effects of these medical variables, a dose
effect was found for the mean orientation and motor cluster
scores. The results are discussed in terms of possible effects of
the infant's early disorganization on the mother-infant
interaction"

Thorp's Methodology Flawed

Thorp is, unfortunately, no expert on trial methodology, as he
demonstrated with his own. He committed at least two major
breaches of protocol, and later admitted that he hadn't even been
aware that what he had done broke the rules. I have never run a
trial, and don't consider myself an expert, either, but as soon as
I read Thorp's paper, I knew he was in trouble. Sure enough, the
mistakes were pointed out in the letters to the editor, and
Thorp's reply was where he had to admit he didn't even know what
those rules were. (Nothing unethical, just matters of maintaining
proper blinding, and under what conditions you can properly
terminate a trial prematurely, as they did.)

In short, Thorp is in a pretty awkward position to be criticizing
the methodology of anybody else's study.

Can you tell me more about what his mistakes were? I'd be really
interested in learning more about how they may have thrown off his
results.

A couple of other people asked this, so I'm taking the liberty of
posting a response to the list. The answer, unfortunately, is
technical and boring.

Trials sometimes are terminated prematurely if a clear advantage
of one treatment or the other is emerging. But there are a few
rules about doing this. First, the data have to be examined by
somebody outside the trial. If one of the people conducting the
trial peeks at the data prematurely, they become
"contaminated"--this is because they may become convinced (by some
slight advantage showing up) that one treatment is better, and
thus not treat all enrolled patients equally. (The physician's
belief in the efficacy of a treatment has repeatedly been shown to
have an independent effect on the strength of the treatment
measured.) Thorp looked at the data himself several times, but
then continued running the trial.

Second, to eliminate the possibility that random fluctuations in
the trend of the accumulating data are mistakenly interpreted as
being significant when they are not (e.g., 8 of the first 10
patients may improve with treatment compared to 1 with placebo,
just by chance, while if the trial is allowed to continue the
trends may even out and the treatments turn out to be equivalent).
Therefore, you have to use a more stringent level of statistical
significance when evaluating the data prematurely than you would
at the end of the trial. Thorp used the end-of-trial statistical
methods, instead of the peek-at-the-data-prematurely methods. We
will, unfortunately, never know whether the big difference Thorp's
study found would have remained if they had continued to enroll
all the patients they had planned to. (Thorp himself admitted in
the response to the letters that he thought their results
overestimated the real difference in c-section rates that
epidurals cause.) It's really too bad, because otherwise their
methodology was pretty darn good, and had the best chance yet of
nailing down a definitive answer as to whether epidurals increase
the risk of c-section, but because he blew these critical points,
fans of epidurals can dismiss his results and say the relationship
is still unproven.

[from ob-gyn-l]

There is, as you probably all know, great controversy over
whether the use of epidurals increases the likelihood that a woman
in labor (especially a nulliparous woman) will be diagnosed with
dystocia (nonprogressive labor) and therefore get a cesarean
section. There have been 2 randomized controlled trials in the US
(that I'm aware of), both of which I read carefully yesterday, and
a couple of others outside the US, which I haven't read. The 2 US
studies both had significant methodological problems. One was
terminated early (and, it turns out, improperly) due to apparent
achievement of statistical significance much earlier than the
authors had anticipated. The other went so far out of its way to
allow women freedom to opt out of the assigned trial arm that they
couldn't analyze by intention-to-treat, and therefore severely
compromised the whole point of randomization. There are also
numerous retrospective studies on this question, with conflicting
results.

Questions:

Do you believe that the scientific evidence to date
adequately supports the proposition that epidurals increase the
c-section rate?

Separately, does your personal, anecdotal experience lead you
to believe that epidurals increase the likelihood that the
recipient will end up with a c-section?

I hope I'm not prematurely cutting off votes, but here are the
results:

Do you believe that it has been adequately demonstrated,
scientifically, that use of an epidural increases a woman's chance
of c-section?

Yes: 4
No: 14
Other: 2

Does your personal experience lead you to believe that it does,
independent of the published literature?

Yes: 5
No: 9
Other: 5

We see again the need for a pilot survey to work out
unanticipated problems with question wording. For example, some
people wanted to say that it increases the risk for some patients
and lowers it for others, or that it increases the risk if given
early but not if given late. I tried to put these into "other." I
had to disregard 1 or 2 free-form answers that I couldn't figure
out how to classify.

Risks to the Mother

Database of epidural complications needed

Experts have called for the establishment of a national database to
identify the major complications that arise from epidural pain
relief.

The decision came after a number of serious problems were
identified from a 6-year UK study carried out between 2000 and
2005.

"Although relatively rare, these complications are serious and
point to the need for regular surveys to be carried out after
epidural pain relief to identify risk factors and the scale of the
problem," said Iain Christie from Derriford Hospital in Plymouth.

The scientists discovered that 12 out of 18,100 patients
developed major complications after receiving epidural pain
relief.

Six patients developed epidural abscesses, three suffered from
meningitis, and three developed blood clots.

"We would strongly recommend that all acute pain services
supervising epidural pain relief after surgery perform a regular
survey to identify patients who have suffered one of these
complications," said Christie.

"These results should then be stored in a national database to
provide a more accurate estimate of the risk of these
complications," he added.

Childbirth
turns
tragic, then joyful
A lifeless woman (Tracy Hermanstorfer) and her baby are revived in
a Colorado hospital on Christmas Eve.
This newspaper report omits the mention of the epidural.

Exclusive
Interview
with ABC News / Good Morning America [12/30/09]
This is where she says, "After they started the pitocin and stuff
like that, I felt a little weird."
Sitting up for the epidural, and it wasn't until afterwards that
she lay down and said that she was tired, and that's when the
whole nightmare started.
She started going numb and everything in her legs, so she laid
down to take a nap, and she wasn't waking up.

It's worth listening to this interview to hear how the OB dances
around the possibility that the epidural could have caused this
crisis. She says she doesn't have a great explanation. She
talks about all sorts of things and kind of blurs the effects of
cardiac arrest from an epidural and cardiac arrest from eclampsia,
where we do not expect woman to recover so quickly. And she
doesn't mention whatever drugs they were busily giving the woman
to reverse the effects of the epidural drugs . . . Narcan maybe?

I wonder how much the problem with the unusual effects of the
anesthesia also affected the baby. Fortunately, it appears
that the baby responded well to normal resuscitation efforts.

And an aside to the interviewer who said that they were doing the
surgery without anesthesia. An epidural is a form of
anesthesia; it's called regional anesthesia rather than general
anesthesia, where someone is unconscious.

After listening to this interview, it seems pretty clear that the
respiratory arrest and cardiac arrest happened pretty soon after
the administration of the epidural. These are known risks of
epidural:

Every birth is a miracle, and I don't wish to detract in any way
from the miracles of c-section, CPR, and Neonatal Resuscitation
when lives are in danger; each of these interventions worked
marvelously to save the lives of this mother and baby once the
crisis occurred. But I think it's a disservice to this
family and all birthing families to pretend that the epidural
isn't the most obvious cause of the crisis in the first place.

The mom's quick recovery and the baby's straightforward
resuscitation suggest that there was no underlying pathology and
that the life-threatening situation could be attributed completely
to the epidural and associated interventions.

But if the family wants to focus on the miracle of birth, I'm
sure the doctors and the hospital aren't going to try to change
their minds. After all, which sounds better:

1) They were the anointed instruments in the hands of God to
effect a Christmas miracle and save the life of this mother and
baby.

2) The procedures they did on the mother (epidural, etc.) nearly
killed her and her baby.

Happy New Year!

Honestly, I question the quality of care this woman was getting
if she was carrying a 7 pound baby at 33 weeks and nobody
noticed! The baby wasn't in the NICU that night, so we can
assume he wasn't really premature. I hope they did an ultrasound
to check the baby's size before they started pitocin with a
33-week baby.

"If the epidural needle or catheter enters the subarachnoid
space, either during insertion or because of catheter migration,
the relatively high volumes of epidural anesthetic can cause high
spinal anesthesia, increasing the loss of function in the
respiratory muscles. The patient will have trouble breathing,
leading to apnea, increasing numbness, or paralysis. This is an
emergency. Immediately calm and reassure the patient. Call the
emergency response team and the anesthesia provider. Have
emergency airway equipment, emergency medications, and suction at
hand to maintain the patient's airway and cardiovascular status.
Follow basic life support guidelines to protect and support the
patient's airway, breathing, and circulation.

"Patient movement can cause the catheter to migrate into an
epidural vein. If unnoticed, this can result in epidural
medication being inadvertently injected into the bloodstream,
causing an overdose. The patient will have ringing in his ears, a
metallic taste in his mouth, a sense of impending doom, and
hypotension, which can progress to unconsciousness and cardiac
arrest. To prevent this complication, the patient should be moved
slowly and carefully by several caregivers and positioned with the
least amount of aid by the patient whenever possible."

I wonder if the mom's heartbeat resumed after the baby was out
because they were finally able to do more effective heart
compressions. That would bring oxygenated blood to the heart
so it could start beating again. Thank goodness!

Yes, thank goodness for CPR! This is exactly the situation
where it is most effective: an essentially healthy person who has
stopped breathing for some reason. You just get some oxygen
into those lungs, compress the heart to circulate it, and then
everything is nicely jumpstarted.

The mom says this is the first time she's needed an epidural
after two previous births. I wonder if the additional pain
was caused by the pitocin contractions or whether she was just
stressed out if she really thought her baby was coming
prematurely. This seems like a situation where good prenatal
care and good labor support would have avoided the need for an
epidural and thus prevented the crisis in the first place.

The mom's quick recovery and the baby's straightforward
resuscitation of the baby suggest the possibility that there was
no underlying pathology and that the life-threatening situation
was caused completely by the epidural and associated
interventions.

I wouldn't expect an average family who's just had a baby to be
able to think critically about what happened, especially with the
distraction of all the media attention they're getting. But
I do wonder about a doctor who cannot think of any explanation for
why a woman who had just gotten an epidural might have cardiac and
respiratory arrest. And I really wonder that she couldn't
explain how the mom might have been revived by the drugs they must
have given her, and she apparently couldn't explain that CPR is
explicitly designed to revive people who are inherently healthy
but have had some kind of short-term insult.

This is not the first story where I have heard a woman say thank
goodness for the cesarean because It saved me and baby's life.
Then come to hear the full story where either mom or baby clearly
had a bad reaction to the epidural and needed the immediate
section. Not one of the people who have shared this with me ever
said it was the fault of the epidural. Never did anyone freely
tell them that it was the most likely cause, which makes me
wonder- is it even written in the records that the bad reaction
occurred and it is most likely caused by the epidural? I
doubt it is, and it is scary because if the woman needs the same
meds again for birth or other procedures her reaction (especially
if it was an allergic reaction versus blood pressure) will likely
be worse the second time!

Often times when I talk to nurses or OBs about medications, I
feel like they live in a different dimension than I do. Their
observations of the effects of these medications seem quite
different than mine. I guess it should not surprise me
though, since I have observed many OBs and nurses not even realize
when a woman was contracting without the damned computer!!! One of
the latest births I attended, my client asked about the risk of
the epidural slowing down labor and the nurse said that does not
happen. Then a minute later explained that she would need Pitocin
with the epidural. When my client asked why, she said, well why
not? It shortens labor and you would not be feeling anything
anyway! My client was well educated (of course) and decided
not to use the epidural. She told me later that one of the reasons
why she decided she did not need it was because it scared her that
she knew more about the epidural than the nurse!

I'm expecting to see a case study in Public Relations after the
way this family and doctor presented the case in the media!

Risks of Routine Placement of Epidural

Personally, I wouldn't risk having the epidural during labor just
because the doctor wants it there as a precaution for c-section.
Having the epidural will definitely put you at greater risk for
c-section as it is part of the "cascade of interventions" you
often hear about on this list. An epidural can stall your labor
necessitating pitocin, or it can cause a deep relaxation of the
uterus and cause the babies to be "stuck" in a position
unfavorable for delivery.

The epidural group showed poorer performance on the
orientation and motor clusters during the first month of life.

Decels/Bradycardia

Look at an EFM printout and you see that it does affect the baby.
The baby's heartbeat stops reacting to the contractions after the
epidural is administered. We accidentally videotaped the EFM screen
before and after the epidural and it is very different. Carol Ann
was born perfectly healthy (except for the fever it gave her that
dropped less than an hour after she was removed). So I guess the
only harm was the 3 days that she had to live with no mom, in a
plastic box with IV's and wires all over her body. Grrrrrrr!

It took years, and a number of people telling me I was off base,
to understand how epidurals cause variable decelerations.
Epidurals cause a generalized vasodilation and a subsequent drop
in blood pressure. This I speculate causes vasodilation of the
arterial blood supply feeding into, and probably within the
placenta bed itself. Causing some kind of change in pressure
gradient that gets passed on to the baby. If more of the fetal
blood is in the placenta, then the intraumbilical hydrostatic
pressure will be lower and the any cord compression will be
exaggerated. Also, when they drained this woman's overdistended
bladder, that caused a big shift of fluid within her body that
could cause a temporary drop in blood pressure, producing
variables. Just like when a pp mom walks to the bathroom, pees,
then passes out. Also, great trivial pursuit question: What's the
number one cause of fever in labor??? Epidurals!

[from ob-gyn-l]

Anesthesia induced bradycardia is unfortunately common. It
results from peripheral vasodilatation and a "steal" phenomenon
from the uterus with a drop in blood flow/oxygenation. This has
been well documented in fetal lambs and cannulation of maternal
uterine vessels. It occurs even in the absence of a drop in
maternal blood pressure (there is almost always a widening of
pulse pressure and a drop in mean arterial pressure). The
treatment is ephedrine for the mother, which results in a prompt
recovery of the fetus.

It is NOT a reason for c/section. An obstetrician who would
section for a bradycardia when the cause is known and treatable
without the trauma and risk of a stat c/section, IMHO needs
re-education and supervision by his/her peers until his/her
decision making improves.

This is a phenomenon we have all seen. My question is how long
would you wait for the bradycardia to resolve? Would you give
ephedrine even if the maternal BP is normal?

Depends on how the strip looked just prior - if it had good beat
to beat variability and accelerations - I might be more patient,
knowing we started with good cardiac reserve.......and whether it
is accompanied by hypertonus.

The decel typically lasts 5 to 8 agonizingly long minutes. It is
usually followed by a tachycardia with decreased beat to beat
variability (due to rate) and then a return to baseline and normal
variability. The tachycardia is required since in a fetus
CO (cardiac output) = HR (heart rate) ......since they don't
really vary their stroke volume.

Other Ways Epidurals Harm Baby

How about a study looking at the effects on mother-infant bonding
and epidurals? I see a real difference in the way a mom will greet
and bond with their baby if they have had an epidural. Especially
the epi. for their convenience as opposed to the rare mom where it
really does get the baby out when nothing else has worked.

And what about a study looking at the effect of a long duration
epidural on the baby's ability to have a coordinated suck? It can
take these babies 24 hours or more to get their sucking act
together. Anyone else seen this?

One hospital here has a 80-85% epidural rate and a 29% section
rate. I can't believe that they are not related. This new
"epidurals are wonderful and have no side effects. Everyone should
get one!" trend is such a disservice to women and their babies.
What are they thinking?

A local lactation consultant told me about a study involving
sheep. The sheep were anesthetized (w/epidural?) during
their labor and delivery. Each ewe that was anesthetized
abandoned its baby. Anyone have more information about this
study?

I was at ICEA in Atlanta this past weekend. The absolute
highlight for me was Dr. Michel Odent OB/GYN from France speaking
on the Future of Civilization if we continue to bring babies into
the world under epidural anesthesia. He spoke of ewes that were
given epidurals over in Europe and then studied. He said that
basically they abandoned their young. And that on a basic
mammalian instinctual level, that is what is going on right now.
That human intelligence keeps us from being totally removed, but
that the basic comparison is definitely there.

He also listed a study of taking the blood from mother rats immed
pp and injecting the blood into virgin rats. The virgin rats then
behaved as mothers. Terkel and Rosenblatt 1968.

Dangers of Epidural Placement
by Incompetent Anesthesiologist

There was recently a maternal death from misplacement of an
epidural by an anesthesiologist under the influence of drugs.

This seems to be a very different issue. It is less about the
safety of the procedure and more about the incompetence of the
medical professional involved. The problem appears to have arisen
as a result of the MD's substance abuse and not directly from the
procedure itself. This would be a risk no matter who the
healthcare provider was and no matter what the medical approach
was.

Yes, it is a risk, and it should be mentioned in informed
consent. I think it would be particularly interesting to know what
the rate of drug abuse among MDs is.

I've heard it's relatively high, given their easy access to drugs
and the abusive conditions of residency; it's very tempting to
take drugs that will make you feel like you have extra energy.

I, too, have read and heard on television shows that the rate of
drug abuse among the medical profession is higher than that of the
general population. As you stated, it is due to the easy access to
medication and a stressful job situation. Also, my opinion is that
they might perceive the drugs they have access to as "safer" than
those you buy on the street. In addition, this type of drug use
may be easier for them to rationalize since they are not buying
them "illegally." The drugs may be readily available in pill form,
rather than by injection, which is easier to take and view as not
as bad.

This information must be taken into consideration for any woman
consenting to an epidural.

I agree the temptation and the availability of drugs is greater
to medical professionals but I think these are the things one must
consider when choosing their birth professional. Although not
everyone has as easy access to prescription medication as MD's
(and nurses for that matter), all adults in our culture have easy
and legal access to alcohol which when abused , can have
disastrous effect.

I have never heard of anyone's choosing which anesthesiologist
would place their epidural. Typically, the anesthesiologist on
duty wanders in when the woman is in enough discomfort that she
might actually want him to go ahead and place the epidural even if
she knew for a fact that he were under the influence.

Did anyone out there actually select their anesthesiologist ahead
of time?

I'm beginning to attach new meaning to the little remarks that
sympathetic nurses make when they hear that Dr. So-And-So is on
duty to come place an epidural. Sometimes they'll say something
like, "Oh, they're very good." Well, what does that mean about the
others, who maybe aren't so good?

My friend had a terrible epidural headache from a botched
epidural placement. She got the blood patch and it worked. The Dr
told her that the other Dr screwed the epidural up. Blamed it on
lack of sleep!! She still has the headache though. He said that
this could last awhile.

05:17 PM ET 09/03/98 - Reuters

Young UK doctors have drink, drug problems-survey

LONDON, Sept 4 (Reuters) - Many young British doctors drink too
much and use cannabis and other illegal drugs, according to a
survey released on Friday.
The poll of 114 junior doctors in northeastern England, published
in a letter in The Lancet medical journal, showed that more than
60 percent drank more alcohol than the recommended safe limits.
Over 35 percent of male doctors and 19 percent of female
physicians also admitted using cannabis and up to 13 percent also
took other drugs.
``The current drinking habits, illicit drug use, and stress in
some junior doctors is of concern, not only for their own well
being, but also how they affect patients' care,'' said Dr Farhad
Kamali of the University of Newcastle, who conducted the study
said.
The British Medical Association (BMA) said the findings were
consistent with its own research into the habits of junior
doctors.
The survey was released a day after Dr Patrick Dixon, a British
AIDS expert and author, called for random drug testing of doctors
because alcohol and drug abuse.
Dixon, the author of book ``The Truth About Drugs,'' said the
problem posed a significant threat to public health because
patients' lives were being put at risk.
``With around 10 percent of all doctors either intoxicated or
withdrawing (from drugs or alcohol) we are faced with the fact
that significant numbers of doctors have impaired judgment because
of addiction,'' Dixon said in a telephone interview.
He claimed that more than 1,000 addicted doctors in London were
addicts but said their colleagues were reluctant to identify them
because of fear of retribution.
The BMA released a report earlier this year that confirmed drug
and alcohol addiction was a problem in the profession.
``Our estimate is that up to 10 percent of doctors may have a drug
or alcohol problem at some time in their working lives,'' a BMA
spokeswoman said.
But she said the BMA was not convinced of the benefits of random
testing which would also involve civil liberty issues.
``Up to now we haven't seen evidence that a random drug testing
policy is justified and would be effective and fair,'' she said.

Recovering from Pharmaceuticals
Received during Labor and Birth

"The drugs used for surgical or dental anesthesia can linger in
the body for quite some time. One dose of homeopathic Phosphorous
30C can help to cleanse the body of anesthetic drugs and relieve
any unwanted side effects." For other tips on homeopathics,
see the EMAZING.com
archives
of the Homeopathic Health Tip of the Day